Provider Demographics
NPI:1205326162
Name:CARSON FAMILY DENTISTRY LLC
Entity type:Organization
Organization Name:CARSON FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:R
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:CARSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:440-543-1234
Mailing Address - Street 1:8505 TANGLEWOOD SQ STE T17
Mailing Address - Street 2:
Mailing Address - City:CHAGRIN FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44023-6400
Mailing Address - Country:US
Mailing Address - Phone:440-543-1234
Mailing Address - Fax:440-543-1205
Practice Address - Street 1:24300 CHAGRIN BLVD
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122
Practice Address - Country:US
Practice Address - Phone:216-464-0442
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:R CHRISTOPHER CARSON DDS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-16
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH208911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty